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REIMBURSEMENT REO ST - UNDERGROUND STORAGE E TANK CLEANUP FUND <br /> CLAIM NO. 009209 REGION.• 5 REIMBURSEMENT NO. <br /> CLAIMANT: - Flag City,L.P. <br /> CO-PAYEE: None <br /> JOINT CLAIMANT.• Bokides Family L.P. <br /> Riddle & Isola <br /> Michelle Mateo <br /> CLAIMANT ADDRESS: 7488 Shoreline Drive, Ste. B-1 - <br /> Stockton CA 95219 <br /> CONTAMINATED SITE. Saddle City Chevron <br /> ADDRESS: 6421 Paddock Pl. <br /> Lodi, CA 95242 <br /> LETTER OF COMMITMENT AMOUNT: $40,000 AMENDMENT: 0 <br /> PROJECT COSTS INCURRED TO DATE APPROVED FOR <br /> (This Section to be completed by claimant) PAYMENT (TO DATE) <br /> (State Use Only) <br /> 1. CORRECTIVE ACTION COSTS $ $ <br /> (Costs entered here must be cumulative, 4 y� <br /> total-to-date, NOT INCREMENTAL. <br /> See Reimbursement Request Instructions) <br /> 2. THIRD PARTY JUDGMENT $ $ <br /> 3. DEDUCTIBLE (Subtract) $ (5.000) $ (5,000) <br /> TOTAL (Lines 1, 2 & 3) $ $ <br /> CERTIFICATION. <br /> I have read and agree with the "Conditions of Payments" (Exhibit I), listed on the reverse side of this document. <br /> NOTE: This request CANNOT BE PROCESSED unless the "Conditions of Payments"are included on the <br /> reverse side when submitted. <br /> The costs claimed have been incurred and have been paid or will be paid within thirty (30) days of receipt of the <br /> funds requested hereby. If such costs have not been paid within 30 days,funds received under this request will <br /> be returned to the State Water Resources Control Board. <br /> CLAIMANT SIGNATURE: DATE: <br /> STATE USE ONLY: APPROVAL FOR PAYMENTS <br /> $ LESS: $ <br /> Approved for Pcgtnent to Date Previous Payments - Amount Due <br /> Reviewed By: Title: - Date: <br /> Approved By: Title: Date: <br /> Form USTCF-REQ(Rn c_ 6/93) <br />